Developing quality indicators for older adults: transfer from the USA to the UK is feasible.

BACKGROUND: Measurement of the quality of health care is essential for quality improvement, and patients are an underused source of data about quality of care. We describe the adaptation of a set of USA quality indicators for use in patient interview surveys in England, to measure the extent to which older patients receive a broad range of effective health care interventions in both primary and secondary care. METHOD: One hundred and nineteen quality indicators covering 16 clinical areas, based on a set of indicators for the care of vulnerable elderly patients in the USA, were reviewed by a panel of 10 clinical experts in England. A modified version of the RAND/UCLA appropriateness method was used and panel members were supplied with literature reviews summarising the evidence base for each quality indicator. The indicators were sent for comment before the panel meeting to UK charitable organisations for older people. RESULTS: The panel rated 102 of the 119 indicators (86%) as valid for use in England; 17 (14%) were rejected as invalid. All 58 indicators about treatment or continuity and follow up were rated as valid compared with just over half (13 of 24) of the indicators about screening. CONCLUSIONS: These 102 indicators are suitable for use in patient interview surveys, including the English Longitudinal Study of Ageing (ELSA). The systematic measurement of quality of care at the population level and identification of gaps in quality is essential for quality improvement. There is potential for transfer of quality indicators between countries, at least for the health care of older people.

Determinants of aerosolized albuterol delivery to mechanically ventilated infants.

An in-vitro lung model and a volume ventilator were used to evaluate the delivery of aerosolized albuterol through an infant ventilator circuit. We compared the following: continuous nebulization (CNA) and intermittent nebulization (INA); various nebulizer gas flows, 5.0, 6.5,and 8.0 L/min; and duty cycle of 33% and 50%. The efficiency and consistency of aerosol delivery by metered-dose inhaler (MDI) with four different spacer devices and by nebulizer positioned at the manifold and at the same position as the MDI were also evaluated. A volume ventilator (Servo 900B) was used with settings selected to reflect those of a moderately to severely ill 4-kg infant. A 3.5-mm endotracheal tube was used in all experiments. A specific type of nebulizer used (Airlife Misty Neb; Baxter; Valencia, Calif) and several spacers were studied (Aerochamber and Aerovent, Monaghan Medical Corporation in Plattsburgh, NY [corrected]; ACE, Diemolding Healthcare Division in Canastota, NY [corrected]; and an in-line MDI adapter, Instrumentation Industries Inc, Pittsburgh). CNA delivered significantly more aerosol to the lung model (4.8 +/- 0.6% of the starting dose) than INA (3.8 +/- 0.3%; p<0.01). There was a significant stepwise decrease in aerosol delivery with increasing nebulizer flow (4.8 +/- 1.3% at 5.0 L/min; 3.7 +/- 1.1% at 6.5 L/min; and 2.7 +/- 1.1% at 8.0 L/min). Increasing duty cycle did not significantly affeet delivery. Overall the spacers with MDI were more efficient than the nebulizer in either position delivering about twice the percentage of the starting dose than the nebulizers. All modes of delivery, except the Aerochamber, demonstrated a marked degree of variability. Most of the starting dose of albuterol either remained in the nebulizer (30.4 +/- 6.0% at 5.0 L/min and 25.3 +/- 4.1% at 8.0 L/min) or was deposited in the inspiratory tubing (34.7 +/- 0.7% at 5.0 L/min and 43.7+/- 4.9% at 8.0 L/min) in our system. In conclusion, we have confirmed that aerosol delivery depends on the mode of delivery and the operating conditions. Although delivery with an MDI and spacer is more efficient than a nebulizer, both methods may produce high variability depending on the method or spacer used.

Therapeutic aerosol delivery during mechanical ventilation.

OBJECTIVE: To provide an overview of aerosol drug delivery during mechanical ventilation in the pediatric and adult populations. DATA SOURCES: Published articles and abstracts identified in a MEDLINE search (1984-July 1994) were reviewed. STUDY SELECTION: All articles and abstracts found, including review articles, in vivo and in vitro studies, case reports, and case series pertaining to issues involving aerosol delivery during mechanical ventilation, were reviewed. No predetermined selection criteria were used to exclude studies. DATA EXTRACTION: Percent delivery of the starting dose to either the patients or the various in vitro lung models, as well as each variable possibly affecting delivery for each study, were tabulated for each study reviewed. DATA SYNTHESIS: The delivery of therapeutic aerosols to endotracheally intubated and mechanically ventilated patients presents a unique challenge for healthcare providers. Delivery can be affected by the diameter of the endotracheal tube and ventilator circuitry, type of ventilator, ventilator modes, type of delivery device, and how the delivery device is operated and introduced into the ventilator circuitry. The drug being aerosolized may behave differently from one delivery system to another. The proper operation of each device requires attention to positioning in the ventilator circuit as well as the mode of ventilation. CONCLUSIONS: No apparent advantage exists for metered-dose inhalers with a large-volume adapter over jet nebulizers, as each method of delivery is capable of similar efficiency (5-15%). Sufficient attention to detail, including the use of an efficient nebulizer and/or adapter and proper placement and operating method, is required to provide optimal delivery. For bronchodilator administration, careful monitoring of outcomes will provide the most optimal dosing schedule.

Aerosolized beta 2-agonists do not induce bronchial hyperreactivity in healthy adults.

OBJECTIVE: To determine whether regular administration of beta 2-agonists could induce bronchial hyperreactivity in nonasthmatic volunteers. DESIGN: A prospective, randomized, double-blind, placebo-controlled, crossover clinical trial of 2 weeks therapy with a 2-week washout period between each treatment period. Treatments were albuterol or matching placebo as 2 inhalations 4 times daily. SUBJECTS: Ten healthy, nonsmoking women 27-37 years old. SETTING: General clinical research center of a tertiary care university hospital. MAIN OUTCOME MEASURES: Baseline spirometry and methacholine bronchoprovocation studies were performed immediately prior to, 12 hours following, and 1 and 2 weeks following each treatment period. RESULTS: No change was detected in either baseline spirometry or methacholine responsiveness. CONCLUSIONS: This suggests that if beta 2-agonists induce a rebound bronchial hyperreactivity, it is not the result of the production of tolerance or a direct effect on bronchial smooth muscle.

Safety of continuous nebulized albuterol for bronchospasm in infants and children.

OBJECTIVE: To determine the incidence of cardiotoxicity in infants and children who receive continuous nebulized albuterol (CNA) for bronchospasm. DESIGN: Prospective, case series. SETTING: A university pediatric intensive care and pediatric subacute units. PATIENTS: Nineteen infants and children who received CNA for at least 24 hours. INTERVENTIONS: None. MEASUREMENTS: Creatinine phosphokinase (CK) was measured at the time of admission and then at 12, 24, 48, and 72 hours while the patient received CNA. Isoenzyme CK-MB fractions were measured if CK concentration was > or = 250 IU/L. One electrocardiogram was obtained for each patient during CNA treatment. All patients had continuous cardiac monitoring during continuous nebulization therapy. MAIN RESULTS: Creatinine phosphokinase levels remained within normal limits for 16 patients during CNA treatment. Three patients had elevated CK and in two CK-MB fractions were elevated at one measurement. None of the electrocardiograms showed evidence of ischemia and no arrhythmias were noted during CNA therapy, even in the patients with elevated CK-MB fractions. CONCLUSIONS: Continuous albuterol therapy appears to be safe in our patient population as there was no significant evidence of cardiotoxicity. The significance of the transient elevation of CK-MB without other evidence of cardiotoxicity remains to be determined.

Early ribavirin treatment of respiratory syncytial viral infection in high-risk children.

A 3-year prospective, blinded, multicenter study was done to assess the efficacy of early ribavirin intervention in mild respiratory syncytial virus illness in children with bronchopulmonary dysplasia or with congenital heart disease. A cohort of 178 children younger than 36 months of age with bronchopulmonary dysplasia or congenital heart disease were followed. Forty-seven infants whose respiratory syncytial virus infection resulted in mild symptoms of less than or equal to 72 hours' duration received ribavirin (n = 20) or water placebo aerosol (n = 27) either in a hospital or at home. Outcome measures included respiratory and analog score, room air oxygen, saturation, and oxygen flow needed to maintain saturation at greater than or equal to 91%. No difference in age, gender, family size, passive smoking, baseline oxygen saturations in room air, or duration of symptoms before treatment was found between groups. After 3 days of therapy, ribavirin produced a greater rate of improvement of analog scores (p = less than or equal to 0.001), lower oxygen requirements (p = 0.01), and higher oxygen saturation (p = 0.01). Respiratory scores and total hospital days did not differ significantly between the groups. Treatment failure occurred in 2 of 20 children (10%) in the ribavirin group versus 5 of 27 children (18%) in the placebo group, a nonsignificant difference. No child required assisted ventilation or had an adverse reaction. We conclude that early ribavirin therapy may help to reduce morbidity from respiratory syncytial virus infection in high-risk young children.

Repeated oral administration of activated charcoal for treating aspirin overdose in young children.

The data from our two patients indicates that gastrointestinal dialysis with repeated oral doses of activated charcoal may significantly enhance the elimination of overdoses of salicylate in young children. Limited experience precludes precise recommendations, but current evidence suggests that gastrointestinal dialysis should be evaluated further for treating pediatric salicylate intoxication.

Safety of frequent high dose nebulized terbutaline in children with acute severe asthma.

Forty-four Pediatric Intensive Care Unit (PICU) admissions for acute severe asthma in 27 children between 8/80 and 10/86 were reviewed to determine the safety of prolonged administration of frequently nebulized terbutaline. The mean dose of nebulized terbutaline was 0.2 mg/kg/dose (range = 0.1 to 0.4 mg/kg/dose) given at a mean frequency of 2.4 +/- 1.2 hours. Seven patients received continuous nebulization at a dose of 0.4 +/- 0.2 mg/kg/h. All patients were placed on continuous cardiorespiratory monitoring. Emergency room therapy was determined by the primary emergency room physicians. Upon admission to the PICU, the mean +/- SD heart rate was 150 +/- 21 bpm and the respiratory rate was 44 +/- 16 bpm. After institution of therapy, these parameters decreased to a similar degree in parallel. The maximum decrease after 36 hours was 28% and 37% for heart rate and respiratory rate, respectively. No cardiac arrhythmias were noted. The initial PaCO2 upon admission to the PICU was 32 mm Hg (range = 24 to 44 mm Hg), the maximum decrease in PaCO2 generally occurred during the 6-hour to 12-hour time interval following admission. We conclude that frequent administration of high doses of nebulized terbutaline is safe in the management of acute severe childhood asthma even in the setting of prolonged administration to the hospitalized child.

Mechanical ventilation in pediatric patients.

Mechanical ventilation in infants and children is guided by the same principles used in ventilating adults. The child's unique anatomy and pulmonary physiology, however, require special considerations. An understanding of these differences will enable the physician to approach the ventilatory management of pediatric patients in a logical manner.

Comparison of the effects of intravenously administered aminophylline and inhaled isoproterenol on normal airways.

Although beta-agonists and anticholinergics have been well documented to alter the resting tone in normal airways, the effects of aminophylline on normal airway function is controversial. We therefore studied the effects of intravenously administered placebo and aminophylline, inhaled isoproterenol, and intravenously administered aminophylline plus inhaled isoproterenol in 8 nonasthmatic subjects using full and partial flow-volume curves, plethysmography, and respiratory resistance as measured by forced oscillation. Isoproterenol, as has been demonstrated previously, caused improvement in FEV1 FEF50, and the flow of a partial flow-volume curve at 75% of the VC (PFEF75). Intravenously administered aminophylline at therapeutic concentrations (17.0 to 22.4 mg/L) resulted in improvement in FEV1, PFEF75, and the total respiratory resistance. Aminophylline and isoproterenol administered together produced additive effects. Thus, contrary to other studies, intravenously administered aminophylline produced a small but significant effect on normal basal airway tone that was less than that seen after an adrenergic agent but proportionally similar to the effects seen in asthmatic subjects.

Effects of theophylline on inhaled methacholine and histamine in asthmatic children.

The effects of a therapeutic serum theophylline concentration on inhaled methacholine and histamine were studied in 8 stable, moderately severe asthmatic children 8 to 15 yr of age. Placebo or theophylline in a hydroalcoholic solution was administered in a double-blind fashion, and standard histamine and methacholine challenges were performed following both placebo and theophylline. Serum theophylline concentration averaged 13 mg/L (range 4.0 to 22.1). Theophylline caused a significant increase (p less than 0.01, paired t test) in provocative dose for a 20% drop in FEV1 (PD20 FEV1) for both methacholine (from a mean of 19.1 to 57.5) and histamine (75.9 to 144.5). This effect did not correlate with the small (7.6% increase in FEV1) but significant bronchodilatation produced by theophylline. We conclude that theophylline in doses that achieve serum concentrations in the usual therapeutic range produces significant attenuation of the bronchoconstrictor response to methacholine and histamine challenges in asthmatic children. The mechanism and therapeutic implications of this remain undefined.

Sustained-release theophylline. Pharmacokinetic and therapeutic comparison of two preparations.

The serum theophylline concentration profiles and clinical efficacy of two sustained-release theophylline tablets (Quibron-T/SR and Theo-Dur) were compared in 13 asthmatic children requiring continuous theophylline therapy. Quibron-T/SR and Theo-Dur, administered every 12 hours in the same dose for one week, were evaluated in a multiple-dose randomized crossover study. At the end of each week, serial serum theophylline concentrations were measured and spirometry and body plethysmography were performed. No significant differences between treatments were found in bioavailability, adverse effects, clinical symptom scores, or pulmonary function in spite of the fact that Quibron-T/SR and Theo-Dur produced significantly different serum theophylline concentration profiles as measured by a mean percent of fluctuation in serum theophylline levels of 143 for Quibron-T/SR and 65.7 for Theo-Dur. Over the short term of the study the pharmacokinetic differences did not produce significant differences in clinical efficacy.